Insurance Life Request Form

INSURANCE LIFE REQUEST FORM

APPLICANT / INSURED INFORMATION

Applicant Name:

Date of Birth:    Social Security / Tax ID:

Primary Phone:    Email Address:

Yes    No

Insured Date of Birth:    Insured SSN / Tax ID:

POLICY DETAILS

Policy Type: Term Whole Universal Variable Other:

Requested Effective Date:    Requested Term / Policy Period End:

Proposed Premium Amount:    Premium Frequency: Monthly Quarterly Annually

COVERAGE OPTIONS / RIDERS

Select desired riders / endorsements (check all that apply):

Accidental Death Benefit    Waiver of Premium    Guaranteed Insurability

Accelerated Death Benefit (Living Benefit)    Chronic Illness Rider    Child Term Rider

BENEFICIARY DESIGNATION

Primary Beneficiary 1

Contingent Beneficiary

Note: Primary and contingent beneficiary percentage shares must total 100% for each designation category. The insurer may require additional documentation to verify beneficiary identity and capacity.

MEDICAL AND RISK DECLARATIONS

Within the past 5 years, has the proposed insured been diagnosed with, treated for, or had symptoms of any of the following? (check Yes or No; if Yes, provide details in the explanation field)

Heart disease / stroke: Yes    No

Cancer (excluding non-melanoma skin cancer): Yes    No

Diabetes requiring medication: Yes    No

Tobacco or nicotine use within the past 12 months: Yes    No

EXCLUSIONS, WARRANTIES, AND CONDITIONS

The coverage applied for is subject to the insurer's standard terms, conditions and exclusions. Coverage may be excluded, limited, or rescinded for: suicide within the contestable period, death resulting from declared or undeclared war, intentional self-inflicted injury, or loss occurring while committing an illegal act. Material misstatement or omission of facts in this request may render the policy voidable or subject to adjustment pursuant to the insurer's contestability rules. The insurer reserves the right to require medical examinations, autopsy, or additional information to determine coverage eligibility and claim validity.

AUTHORIZATION AND CONSENT

By signing below, the applicant authorizes the insurer and its agents to obtain medical records, laboratory tests, and other relevant information from any licensed physician, medical practitioner, hospital or other medically related facility. The applicant authorizes any such provider to release medical information necessary to evaluate this request. The applicant also authorizes the insurer to obtain consumer reports and investigative consumer reports for underwriting purposes. A copy of this authorization is as valid as the original. This authorization shall remain valid for the duration necessary to process the application and any related claims.

I certify that the information provided in this request is true, complete and accurate to the best of my knowledge. I understand that any intentional misrepresentation, omission, or concealment of material fact may result in denial of coverage, rescission of policy, or criminal penalties under applicable law.

I authorize release of medical and other relevant records as described above.

REQUIRED DOCUMENTS CHECKLIST

Please submit the following documents with this request. Check boxes for documents included.

Photographic ID of applicant    Proof of Birth Date    Completed Medical Exam / Lab Results

Initial Premium Payment Method    Other Documents:

CERTIFICATION

I, the undersigned applicant, declare under penalty of perjury that I am the person named in this request, that I am authorized to provide the information contained herein, and that the statements and answers provided are complete and true. I understand that acceptance of this request is subject to underwriting approval by the insurer and that coverage will not be effective until all conditions of acceptance, including payment of premium and any required evidence of insurability, have been satisfied.

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